equity, diversity, and inclusion
An overview of equity, diversity, and inclusion in dermatology, and providing culturally-competent care.
RURAL & REMOTE dermatology
AN OVERVIEW
One in every five people who live on Turtle Island (Canada) are deemed living in a “rural” space. Rural spaces account for over 98% of the land on Turtle Island. 20% of the population belong to rural centres, and thus have unique difficulties in accessing healthcare [1]. Sub-specialty medical practitioners are particularly difficult to access when one resides in a rural location. This issue becomes further complicated when seeking access to dermatologic care. In Ontario, there are an estimated 250 dermatologists [2], which is almost half of the total number of dermatologists on Turtle Island (Canada) [3]. At baseline, there is a lack of dermatologists and extremely long-wait times for an appointment. This is exacerbated by a lack of specialists practising in rural areas. In the United States, it is estimated that less than 10% of dermatologists practise in rural communities [4]. This number is likely significantly lower in Canada, which already suffers from a shortage of dermatologists.
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When considering the impact of poor access to healthcare in rural communities, it is a disservice to ignore the fact that these communities are mostly comprised of Indigenous peoples. It is estimated that over 60% of the Indigenous population in Canada resides rurally, and thus is impacted greatly by lack of access to dermatologic care [5]. Indigenous peoples in Canada are estimated to have the greatest lack of access to dermatologic care [7]. Moreover, there is a significant lack of Indigenous physicians and specialists across Canada. Less than 1% of physicians in Canada identify as Indigenous [6]. Overall, this contributes to a further lack of access because not-only are Indigenous people impacted by rural barriers, but also a lack of identification with practitioners who can provide safe and culturally-relevant care.
resources
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https://www.cbc.ca/radio/whitecoat/wait-times-dermatology-back-logs-avantderm-1.7006685
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https://www.cma.ca/sites/default/files/2019-01/dermatology-e-v2.pdf
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https://www.oecd.org/regional/regionaldevelopment/PH-Indigenous-Canada.pdf
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https://globalnews.ca/news/4769750/access-aboriginal-doctors-struggle-indigenous-population/
RURAL & REMOTE dermatology
STRATEGIES TO IMPROVE ACCESS
What is Tele-Dermatology?
Watch this educational video from the Australian College of Rural and Remote Medicine. It discusses Tele-derm is and how it can be utilised to benefit rural patients.
1. tele- dermatology
UBC - Rural and Remote Teledermatology
Continuing professional development, this presentation discusses the Teledermatology service for rural and remote areas in British Columbia. UBC works in conjunction with Family Physicians to improve access to consultation services, and support diagnostics for those in rural communities.​
2. INVESTING IN RURAL TRAINING
Investing in Dermatology Resident Training in Rural Areas
In the USA, there is a concerted interest in encouraging residents to visit rural locations, and having rural sites with dermatologic training available. The hope is that exposing residents to rural care might make them more keen to move to rural sites as practitioners.
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​Rural Dermatology Training and Expanding Access to Care
This video discusses creating more spaces to practise and train in rural areas as a Dermatologist and Resident.
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Creating More Rural Dermatology Practices
The American Academy of Dermatology explores the need for more access to dermatologic care in rural centres. The following article discusses evidence-based strategies to improve access, with a focus on creating more clinics outside of larger, urban areas.
3. INCREASING INDIGENOUS PRACTITIONERS
A Call To Action - More Indigenous Practitioners
Recruiting and training more Indigenous physicians is a Truth and Reconciliation Call to Action. This is an upstream approach to improving rural/ remote access to specialist care, as more Indigenous physicians can contribute to improving access to healthcare for their own peoples.
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Indigenous Dermatology on Turtle Island
Dr. Asiniwasis is the only practising Indigenous dermatologist in Canada. To learn more about her practice on Turtle Island, check out the link to Origins Dermatology.
Content developed by: Taylore Miller
Edited by: Lauren Fraess, Caden Carver, Kristina Nazzicone
Indigenous dermatology
COMMON SKIN PRESENTATIONS
Indigenous patients face unique issues when accessing Dermatological care on Turtle Island. These issues range from medical education, which has significant under-representation and collaboration with Indigenous peoples (Pan, Yang, & Nambudiri, 2022), to the lack of access in communities themselves (Nguyen, Subhan, Williams, & Chan, 2020). In keeping with Skin Curriculum’s goal to diversify dermatology, as well as improve access to quality care, the following resources have been cultivated. Based on the works from Canada’s sole Indigenous Dermatologist, Dr Asiniwasis, here we highlight the common conditions faced by Indigenous communities as well as their diagnosis and treatment options.
According to Dr Asiniwasis, two of the most common conditions that are under-documented in both Indigenous paediatric and adult populations are atopic dermatitis and skin infections (Asiniwasis et. al., 2021). Barriers can range from:
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a lack of access to physicians
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negative health-care experiences that affect trust
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lack of access to clean drinking water
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and more.
These issues make getting simple treatments for these common conditions incredibly complex for Indigenous peoples (Asiniwasis et. al., 2021). In order to improve access to information regarding the diagnosis and management of these common conditions, several resources have been listed below. These resources also highlight research into management by Indigenous physicians and approaches guided by Indigenous traditional teachings.
ATOPIC DERMATITIS
Content developed by: Taylore Miller
Edited by: Juliette Charbonneau, Lauren Fraess, Iryna Savinova
SKIN INFECTIONS
Video on the clinical presentation, pathology, and treatment of bacterial skin infections:
RESOURCES
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Pan, C., Yang, K., & Nambudiri, V. (2022). Assessment of the representation of black, indigenous and people of colour in dermatology clinical practice guidelines. Br J Dermatol;187(3):443-445. doi: 10.1111/bjd.21273. Epub 2022 Jun 7. PMID: 35349171.
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Nguyen, N., Subhan, F., Williams, K., & Chan, C. (2020). Barriers and Mitigating Strategies to Healthcare Access in Indigenous Communities of Canada: A Narrative Review. Healthcare (Basel);8(2):112. doi: 10.3390/healthcare8020112. PMID: 32357396; PMCID: PMC7349010
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Asiniwasis, R., Heck, E., Amir, A., Ogunyemi, B., & Hardin, J. (2021). Atopic dermatitis and skin infections are a poorly documented crisis in Canada's Indigenous pediatric population: It's time to start the conversation. Pediatr Dermatol;38 Suppl 2:188-189. doi: 10.1111/pde.14759. PMID: 34850439.
Indigenous dermatology
SACRED MEDICINES
The Four Sacred medicines are a very important piece of Indigenous well-being on Turtle Island. Not only are these medicines important for spiritual wellness, but they have also been used to heal a variety of physical ailments. Traditional healing still plays an important role in the medical care of Indigenous patients. Incorporating Traditional Medicine into the care of Indigenous patients has been proven to improve access, outcomes, and adherence [1]. Thus, the Four Sacred medicines are a vital piece of improving Indigenous Skin Health in “Canada”.
Disclaimer: Not a lot of research has been conducted in regards to the Four Sacred Medicines being used in dermatology. These findings are inferred from a variety of studies based on the different biochemical properties of the Four Sacred Medicines. The products listed below are all from Indigenous companies on Turtle Island, with no financial interest in Skin Curriculum. They are simply to represent Indigenous voices and Traditional Teachings that are often missed in scientific study. Miigwetch.
Bashkodejiibik (White Sage)
White sage is a well-known sacred medicine for its use in smudging and ceremony. Bashkodejiibik is still used for its cleansing properties of the mind, body, and spirit. However, it also has several pharmacologic properties that are often concentrated in a variety of skin cleansers [2]. ​
Retrieved from: Cree Board of Health and Social Services of James Bay (CBHSSJB)
Giizhik (cedar)
Cedar is a powerful Traditional medicine that is burned in ceremony to attract the attention of spirit. Giizhik represents both balance and purification, which also speaks to its pharmacological properties.
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Improves wound healing [5]
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Antimicrobial and antifungal [6]
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Anti-inflammatory
Indigenous peoples on Turtle Island continue to use cedar for these properties, as well as for its other ceremonial uses.
Retrieved from: Indigenous Corporate Training Inc.
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Antioxidants which help protect the skin from damage
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Diterpenes such as 16-hydroxycarnosol and rosmadial
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Anti-inflammation
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Flavinoids such as oleanolic acid
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Promotion of wound healing
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Flavinoids such as uvaol [3]
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Restoring collagen and skin elasticity (anti-aging)
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Flavinoids such as ursolic acid and oleanolic acid [4]
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Bashkodejiibik has been used Traditionally as a cleanser for the spirit and for the skin. It can be packaged in creams, balms, and cleansers. Sage has been used as an active ingredient in anti-acne cleansing toners.
Wiingashk (sweetgrass)
Sweetgrass represents the hair of Mother Earth, as it is braided together when harvested out of love and respect. The three strands of the braided wiingashk represent the mind, body, and spirit. Pharmacologically, the properties of wiingashk are as follows:
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Cell rejuvenation and antiaging
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Hyperpigmentation [7]
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Phytol can help reduce melanin production to address hyperpigmentation
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Natural insect repellent [8]
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Phytol and coumarin make an effective natural bug spray
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Wiingashk has many uses to protect and heal the skin. It is often a component of a variety of skin salves used for atopic dermatitis and dry skin to protect and soften!
Retrieved from: The Canadian Encyclopedia; Photo by: Nancy J Turner
Semaa (tobacco)
Traditionally, semaa represents a pathway to the spirit-world. It is given as an offering when asking something of an elder or of Mother Earth. Historically, tobacco has many medicinal uses from its extensive pharmacologic properties.
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Antimicrobial, antioxidant, and anti-inflammatory
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High in Vitamin C [9]
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Historically used for eczema, skin infections, burns, and rashes
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Semaa is one of the four sacred medicines, and is very important to Indigenous peoples. Generally, tobacco is used as an active ingredient to protect the skin.
Retrieved from: Cree Board of Health and Social Services of James Bay (CBHSSJB)
ORIGINS DERMATOLOGY
Origin’s Dermatology is the only Dermatology clinic for Indigenous peoples in Canada. They are frontiers in maintaining Indigenous healthy skin and in caring from Indigenous peoples in a Good Way. Below are the links to Origin’s Dermatology website, where they have numerous Indigenous skin-health research projects listed.
Indigenous SKIN SPECTRUM SUMMIT
This conference in Ethno-Dermatology was started in 2021.
Many researchers passionate for the care of Indigenous patients have utilized this conference as a way to improve advocacy and leadership in EDI-based Dermatology.
amplifying indigenous contributions
Skin Curriculum believes in incorporating Indigenous voices, Traditional knowledge, and teachings into our resource list. This knowledge belongs to Indigenous communities across Turtle Island. As such, we have dedicated this next space to highlight several Indigenous Companies across Turtle Island that helped to inform and inspire our resource space.
Miigwetch for all your contributions.
Skwalwen Botanicals
Squamish, BC
SISTER'S sAGE
VANCOUVER, BC
Sweetgrass Soaps
LANGLEY, BC
Mother Earth Essentials
EDMONTON, AB
Ojibway Naturals
THUNDERBAY, ON
Articles used to inform this pagE
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Allen, L., et. al. (2020). Indigenous-led health care partnerships in Canada. Canadian Medical Association Journal. 192(9): E208-E216. doi: 10.1503/cmaj.190728. Epub 2020 Mar 2. PMID: 32122977; PMCID: PMC7055951
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Srivedavyasasri R, Hayes T, Ross SA. (2017) Phytochemical and biological evaluation of Salvia apiana. Nat Prod Res. 17:2058-2061. doi: 10.1080/14786419.2016.1269096. Epub 2016 Dec 27. PMID: 28025900; PMCID: PMC5505801.
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Carmo, J., et.al. (2020). Uvaol Improves the Functioning of Fibroblasts and Endothelial Cells and Accelerates the Healing of Cutaneous Wounds in Mice. Molecules. 25(21):4982. doi: 10.3390/molecules25214982. PMID: 33126422; PMCID: PMC7662923.
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Kim, Y.J. et. al. (2021). Oleanolic Acid Protects the Skin from Particulate Matter-Induced Aging. Biomol Ther. 29(2):220-226. doi: 10.4062/biomolther.2020.106. PMID: 32952129; PMCID: PMC7921861.
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Heinrich, M. et. al. (2021). Medicinal plants from the Himalayan region for potential novel antimicrobial and anti-inflammatory skin treatments. J Pharm Pharmacol. 73(7):956-967. doi: 10.1093/jpp/rgab039.
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Bisht, A., et. al. (2021) Cedrus deodara: A review of traditional use, phytochemical composition and pharmacology. J Ethnopharmacol. 279:114361. doi: 10.1016/j.jep.2021.114361.
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Gyeong-A, Ko., & Somi Kim, Cho. (2018). Phytol suppresses melanogenesis through proteasomal degradation of MITF via the ROS-ERK signalling pathway., Chemico-Biological Interactions, Volume 286, Pages 132-140, ISSN 0009-2797, https://doi.org/10.1016/j.cbi.2018.02.033.
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Cantrell, C.L., Jones, A.M., & Ali, A. (2016). Isolation and Identification of Mosquito (Aedes aegypti) Biting-Deterrent Compounds from the Native American Ethnobotanical Remedy Plant Hierochloë odorata (Sweetgrass). J Agric Food Chem. 64(44):8352-8358. doi: 10.1021/acs.jafc.6b01668.
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Charlton, A. (2004). Medicinal uses of tobacco in history. J R Soc Med. 97(6):292-6. doi: 10.1177/014107680409700614. PMID: 15173337; PMCID: PMC1079499.
Content developed by: Taylore Miller
Edited by: Juliette Charbonneau, Lauren Fraess, Danielle Solish, Iryna Savinova
ORIGINS DERMATOLOGY
Origin’s Dermatology is the only Dermatology clinic for Indigenous peoples in Canada. They are frontiers in maintaining Indigenous healthy skin and in caring from Indigenous peoples in a Good Way. Below are the links to Origin’s Dermatology website, where they have numerous Indigenous skin-health research projects listed.
Indigenous SKIN SPECTRUM SUMMIT
This conference in Ethno-Dermatology was started in 2021.
Many researchers passionate for the care of Indigenous patients have utilized this conference as a way to improve advocacy and leadership in EDI-based Dermatology.
ATOPIC DERMATITIS TRIGGERS IN INDIGENOUS COMMUNITIES
Atopic Dermatitis (AD) is a chronic skin condition characterized by dry, itchy skin secondary to underlying inflammation. Many triggers of AD have been identified. Internal triggers can be stressors or food allergies. External triggers include exposures to smoking, cold weather, or crowded housing conditions. AD is managed by preventing skin barrier compromise, managing stress, and using moisturizers and hydrocortisone creams.
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Use these resources to further explore AD: ​​
HOW DOES THIS APPLY TO INDIGENOUS POPULATIONS?
Indigenous peoples in Canada have some of the highest rates of AD in the world.
This disproportionate burden remains unexplained, but emerging literature suggests that Indigenous peoples face greater exposure to triggers for AD. In addition to this increased exposure, Indigenous peoples encounter significant barriers to accessing dermatologic care.
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For Indigenous children with AD, the condition is most often classified as moderate to severe. Compounding these challenges, limited access to moisturizers and preventative creams increases the risk of skin infections, as a disrupted skin barrier becomes more vulnerable to pathogens.​
AD TRIGGERS IN INDIGENOUS POPULATIONS
1. The Indigenous housing crisis exacerbates AD triggers, with crowded living conditions contributing to increased exposure to dust, humidity, and black mold.
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Over â…™ of Indigenous peoples live in conditions deemed overcrowded or unsafe
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Federal Underfunding Contributes to the Indigenous housing crisis
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2. Northern/cold climates are known triggers of AD
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Indigenous peoples make up as much as 90% of the population in some northern regions of Canada. A significant proportion of Indigenous peoples live in northern and remote areas, where access to healthcare and resources is limited
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3. Smoking and AD
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Indigenous children in Canada experience the highest rates of exposure to second-hand smoke globally​​
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4. Stress, discrimination and trauma in relation to AD
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Intergenerational trauma is passed down genetically, leading to inflammation in descendants. The traumas endured by Indigenous peoples have become deeply ingrained in their genetic makeup. Studies show that stress effects can be inherited through genetic, epigenetic, and neuroanatomical changes
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Experiencing racism and discrimination is a significant determinant of health. Those who face discrimination often experience poorer mental health and higher stress levels​​
Content developed by: Taylore Shalovsky
Edited By: Olivia MacIntyre, Lauren Fraess, Kristina Nazzicone
ETHNOdermatology
Ethnodermatology is an exciting new sub-branch of dermatology focusing on dermatologic conditions in diverse populations. Historically, people with skin of colour have been underrepresented in medical education. Common skin presentations on light skin can appear completely different on darker skin tones. As a result, many organisations have been striving to improve representation of skin of colour in common skin conditions. Below you can find a variety of resources to facilitate your learning:
overview
For an introduction on The Fitzpatrick Scale (which classifies skin by its reaction to sun exposure), the nuances of diagnosing dermatological conditions in skin of colour, and an overview of common presentations, review the article below:
Gallery
The best way to learn about the presentation of skin conditions in diverse populations is to see them, use the following galleries and photo banks to familiarize yourself with the diverse presentations and manifestations of skin diseases/conditions.
TEST YOURSELF
Try to identify the skin conditions presented in the website gallery below, then scroll over the image to reveal the answer!
Content developed by: Taylore Miller
Edited by: Olivia MacIntyre, Lauren Fraess, Danielle Solish, Iryna Savinova
Decolonizing and Diversifying Dermatology
A large piece of Ethnodermatology involves acknowledging where gaps in quality of care exist. When it comes to decolonizing dermatology, it is vital to learn about these gaps so that each patient receives the care that they deserve. The biggest issues in dermatology involve a lack of representation of skin of colour images in medical education, a lack of diversity in dermatologists, and a lack of access to dermatologic services. These issues need to be addressed in order to ensure that dermatologists are providing decolonized and diversified care to all patient populations (Singh, 2020). Learning more about issues for diverse populations in dermatology is the first step towards reconciliation and diversification.
Listed below are several resources that acknowledge and educate on issues facing diverse populations in dermatology. Easy to read and interesting to reflect upon!
Underrepresentation of Skin of Colour in Medical Education
This article by Usha Lee McFarling opens an interesting dialogue between research articles and patient stories. It addresses the lack of representation of darker skin tones in dermatology references. One of the main goals of Skin Curriculum is to provide resources with more representation (please see the ethnodermatology piece above for more details!)
Racial Disparities in Dermatology
This article by Narla et al. discusses the significant underrepresentation of minorities practicing as dermatologists. They discuss how this underrepresentation ultimately results in down-stream consequences that include decreased representation of diversity in educational resources. Although this article is from the American Association of Dermatologists, Canada is also significantly underrepresented in minorities practicing Dermatology. As an example, there is currently only one practicing Indigenous Dermatologist in all of Canada (2023).
Lack of Access to dermatology in Indigenous and Rural Communities
This article by John Evans reflects on the difficulties of accessing dermatologists in the Northwest Territories. It particularly discusses the increased burden of dermatitis and asthma in Indigenous populations with decreased specialist care!
Content developed by: Taylore Miller
Edited by: Lauren Fraess, Iryna Savinova
CLIMATE HEALTH AND DERMATOLOGY:
​Indigenous views on Mother Earth and Skin Connections
It is not a new concept that the Earth impacts our physical health. For generations, Indigenous peoples were the sacred caretakers of the lands. There is a Traditional understanding that our health impacts Mother Earth, and in turn, her health impacts ours. However, despite Traditional teachings shared by Indigenous peoples for years, only recently has climate change become a topic of interest to Medical Practitioners. Particularly because the health of Mother Earth was ignored by the masses, and we are now seeing the impacts on our own health.
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This topic has particular interest to Indigenous people and Dermatologists alike. In this section, we have provided resources that address the impact of the climate on our health and our skin. It is important to acknowledge Indigenous Traditional teachings, and how we can learn from them to better support Mother Earth. After all, the impact of climate change is felt more deeply by Indigenous peoples, and the solution has been within Indigenous teachings all along.
CLIMATE ATLAS OF CANADA
Incredible resource created by Indigenous peoples that discusses climate change from Indigenous perspectives. Linked is a video that discusses Community-Based solutions to Climate Change rooted in Decolonization.
Land and Nature as Sources of Health and Resilience among Indigenous Youth in an urban Canadian Context: A Photovoice exploration
This article outlines how important Mother Earth is to the wellness of Indigenous peoples. This will hopefully allow for a better understanding as to why climate change so deeply impacts and negatively affects Indigenous peoples.
Climate Change and Dermatology: An Introduction to a Special Topic, for this Special Issue
Focused from the lens of the American Academy of Dermatology, this article discusses the impact that climate change has on dermatologic conditions. In addition, this article discusses vulnerable populations that would be disproportionately affected by the impacts of climate change on health.
Content developed by: Taylore Miller
Edited by: Olivia MacIntyre, Lauren Fraess, Nawar Tarafdar, Iryna Savinova